2 Overview Background Diagnosis ACC/AHA indications for Echo TTE versus TEEDiagnostic Echo criteriaEchocardiographic estimation of outcomeIntracardiac complications of endocarditisSurgical indications by Echocardiography
3 Background Infection of endocardium valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduits
4 Background Infection of endocardium Diagnosis: modified Duke criteria valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduitsDiagnosis: modified Duke criteria
6 4 structural echo findings in Modified Duke Major criteria
7 Background Infection of endocardium Diagnosis: modified Duke criteria valve leaflets, congenital defects, chamber walls or chordae, prosthetic valves/conduitsDiagnosis: modified Duke criteriaNo noninvasive technique can definitively diagnoseEchocardiography has high sensitivity for IE and intracardiac abscessMandatory in the diagnosis and treatment of IEACC/AHA 2006 guidelines on valvular heart disease include recommendations for Echo use in native and prosthetic valve IE
8 Goals of Echo in Possible IE Identify, localize, and characterize masses consistent with vegetationsIdentify new valvular regurgitationExamine prosthetic valve stabilityApply criteria to judge prognosis once vegetation identified
9 Accuracy of TTE Meta analysis 1984: 641 pts* Mean sensitivity of 79% for detecting veg’sMore recently, decreased sensitivity despite tech improvements7 studies, , Mean sensitivity of 62% 4-11? d/t more rigorous case selection or d/t decreased TTE scrutiny now with TEELimitationsUnderestimates size and complexity of large veg’sMay fail to detect small veg’s (< 3 mm)*O'Brien, JT, Geiser, EA. Infective endocarditis and echocardiography. Am Heart J 1984; 108:386
10 Accuracy of TEE More invasive and expensive than TTE High sensitivity in detecting and defining valve vegetationsSame 7 studies from , sensitivity 92% (compared to 62%)4-115 studies w/ similar results for sensitivity also revealed high specificity for TEE and TTE (93% vs 46% sensitivity, 96% vs 95% specificity) 4,8,10-12ACC/AHA guidelines, main role of TEE is:Nondiagnostic TTEProsthetic valve endocarditisAssessment of complications
17 Diagnostic Echo criteria Characteristics of mass likely to be a vegetation:Texture: gray scale and reflectance of myocardiumLocation: upstream side of valve in path of jet or on prosthetic materialMotion: choatic and orbiting, independent of valve motionProlapse into upstream chamber (i.e. MV mass into LA in systole)
19 Diagnostic Echo criteria Characteristics of mass likely to be a vegetation:Texture: gray scale and reflectance of myocardiumLocation: upstream side of valve in path of jet or on prosthetic materialMotion: choatic and orbiting, independent of valve motionProlapse into upstream chamber (i.e. MV mass into LA in systole)Shape: lobulated, amorphousAccompanying abnormalities:abscess, pseudoaneurysm, fistula, prosthetic dehiscence, paravalvular leak, new regurgitant lesion
20 Diagnostic Echo criteria Characteristics of mass unlikely to be vegetation:Texture: reflectance of calcium or pericardium (white)Location: outflow tract attachment, downstream surface of valveShape: stringy or hair-like strands with narrow attachmentLack of accompanying turbulent flow or regurgitation
21 False Positives Most common on TEE Lambl’s excrescences Strands on sewing rings of prostheticsFree sutureRedundant chordae, false tendons in LVChiari’s remnant in RAChordal insertion into normal MVAll of above tend to be highly reflective with echodensity similar to pericardium or aortic root. Dense, fibrotic, non-vibratory nature
24 False Negatives TTE>TEE Cannot definitively rule out endocarditis High sensitivity of TEE (92-94%)Cannot definitively rule out endocarditisLow likelihood of IE if negative TEE in intermediate probability patientIn patients at high risk for IE (prosthetic valve, unexplained bacteremia), repeat examination reasonable
25 Echo Estimation of Outcome TTE:1991 Retrospective study. 204 pts with clinical criteria for IE.*Clinical complications (drug failure, new CHF, embolization, surgery, death) compared to vegetation characteristicsOverall complication incidence 55%Rates similar between native and prosthetic valves as well as between MV, TV, and AVSize of vegetation most powerful predictor of complication10% if 6 mm vegetation, 50% if 11mm vegetation, almost 100% if > 16 mmComplications more frequent with higher grades of mobility and lesion extentVegetation consistency did not predict complications (except for calcified lesions which had no associated complications)*Sanfilippo, AJ, Picard, MH, Newell, JB, et al. Echocardiographic assessment of patients with infectious endocarditis: Prediction of riskfor complications. J Am Coll Cardiol 1991; 18:1191.
30 Echo Estimation of Outcome TEE:Observations on TTE not directly applicable to TEE since given vegetation likely to appear larger on TEE105 pts with IE, 1989*:vegetation > 10 mm = increased incidence of embolization (47% v 19%, p<0.01)Association particularly strong for MV endocarditisVegetation size and location did not predict other rates of complications (CHF, death)178 pts with IE, 2002+:Vegetation mobility confers additional risk beyond vegetation sizeEmbolic incidence higher with vegetation > 15 mm (70% vs 27%) and when vegetation moderately or severely mobile (62% vs 20% compared to low mobility)Embolic rate 83% with large and severely mobile vegetationsObservational studies suggest risk of embolism declines after institution of antibiotic therapyEcho predictors still apply after initiation of antibioticsGreater vegetation size and mobility still predicted late embolic eventsIncrease in vegetation size after antibiotic start also predicted prolonged healing phase and a higher embolic risk*Mugge, A, Daniel, WG, Frank, G, Lichtlen, PR. Echocardiography in infective endocarditis: reassessment of prognostic implications ofvegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989; 14:631.+Di Salvo, G, Habib, G, Pergola, V, et al. Echocardiography predicts embolic events in infective endocarditis. J Am Coll Cardiol 2001; 37:1069.
36 Intracardiac Complications Valvular regurgitationSecondary infection of other valvesLeaflet perforationPerivalvular abscess or fistulaEarly invasion cellulitis (echodense thickening of perivalvular tissue) Necrosis and inflammation abscess cavityAbscess most likely with staph aureusRisk of fistula formationAbscess formation increase in morbidity and mortalityTEE >TTE: 118 pts with IE, 1991, 44 with abscess at surgery/autopsy. 87% vs 28% sensitivity*TEE still imperfect. Additional series 2007 showed TEE detecting only 48% of abscesses (21 of 44 pts)+*Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophagealechocardiography. N Engl J Med 1991; 324:795.+Hill, EE, Herijgers, P, Claus, P, et al. Abscess in infective endocarditis: the value of transesophageal echocardiography and outcome:a 5-year study. Am Heart J 2007; 154:923.
39 Right Sided Endocarditis Tricuspid valve vegetations most common in IV drug usersMost caused by staph aureusInfrequently, R sided endocarditis due to involvement of PVOften diagnosed only by TEEmost literature limited to single case reportsMost reports of R sided endocarditis have used TTEIn 48 IVDU pts with suspected IE, 22 with vegetations+TTE and TEE equally sensitive and specificTEE found no vegetations which were overlooked by TTE although vegetation usually better characterized by TEE+San Roman, JA, Vilacosta, I, Zamorano, JL, et al. Transesophageal echocardiography in right-sided endocarditis. J Am Coll Cardiol1993; 21:1226.
40 Prosthetic Valve Endocarditis Findings suggestive of IE in prosthetic valves:Vegetationperivalvular abscess and fistula formationimpaired leaflet motionvalve rocking suggesting valve dehiscencePerivalvular regurgitation.* Must compare to prior. If no, moderate-severe suggestive of IE (not mild)Echo evaluation can be limited by highly reflective prosthetic materials which block the passage of ultrasoundTEE has higher sensitivity than TTE (82-86% vs 36-43%)13-16NPV close to 100% for TEE in native valve endocarditis but not for prosthetic valves making clinical assessment especially importantAccording to most recent ACC/AHA guidelines, TEE should be first line diagnostic test for possible IE in prosthetic valves
44 SummaryEchocardiogram part of major criteria in Modified Duke CriteriaGoals to aid in diagnosis, localize vegetations, assess for complications of IEMass texture, location, motion, shape, and associated abnormalities importantVegetation size and mobility correlated with embolic complications in multiple studiesTEE more sensitive than TTE. Both highly specific.NPV high for TEE. Role for repeat imaging in high risk patientsTEE better at detecting IE complications such as abscess, fistula, and leaflet perforationTTE = TEE in detecting R sided endocarditis with exception of PV involvementTEE > TTE for prosthetic valve IE and should be pursued directlyACC/AHA guidelines from 2006 include recommendations for use of TTE/TEEGenerally TTE is preferredClass I indications TEE: nondiagnostic TTEs, better assessment of abscess/complications, prosthetic IEClass IIA indications TEE: persistent staph bacteremia without clear sourceACC/AHA for surgical intervention (severe valve dysfunction, abscess, other penetrating lesion)
45 References1. Bonow, RO, Carabello, BA, Chatterjee, K, et al. ACC/AHA 2006 guidelines for the management of patients with valvular heart disease. A report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing committee to revise the 1998 guidelines for the management of patients with valvular heart disease). J Am Coll Cardiol 2006; 48:e1. 2. Bonow, RO, Carabello, BA, Chatterjee, K, et al Focused update incorporated into the ACC/AHA 2006 guidelines for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines (Writing Committee to Revise the 1998 Guidelines for the Management of Patients With Valvular Heart Disease): endorsed by the Society of Cardiovascular Anesthesiologists, Society for Cardiovascular Angiography and Interventions, and Society of Thoracic Surgeons. Circulation 2008; 118:e Role of Echocardiography in Infective Endocarditis. UpToDate Shively, BK, Gurule, FT, Roldan, CA, et al. Diagnostic value of transesophageal compared with transthoracic echocardiography in infective endocarditis. J Am Coll Cardiol 1991; 18: Mugge, A, Daniel, WG, Frank, G, Lichtlen, PR. Echocardiography in infective endocarditis: reassessment of prognostic implications of vegetation size determined by the transthoracic and the transesophageal approach. J Am Coll Cardiol 1989; 14: Jaffe, WM, Morgan, DE, Pearlman, AS, Otto, CM. Infective endocarditis, : echocardiographic findings and factors influencing morbidity and mortality. J Am Coll Cardiol 1990; 15: Burger, AJ, Peart, B, Jabi, H, Touchon, RC. The role of two-dimensional echocardiology in the diagnosis of infective endocarditis [corrected] [published erratum appears in Angiology 1991 Sep;42(9):765]. Angiology 1991; 42: Pedersen, WR, Walker, M, Olson, JD, et al. Value of transesophageal echocardiography as an adjunct to transthoracic echocardiography in evaluation of native and prosthetic valve endocarditis. Chest 1991; 100: Daniel, WG, Mugge, A, Martin, RP, et al. Improvement in the diagnosis of abscesses associated with endocarditis by transesophageal echocardiography. N Engl J Med 1991; 324: Sochowski, RA, Chan, KL. Implication of negative results on a monoplane transesophageal echocardiographic study in patients with suspected infective endocarditis. J Am Coll Cardiol 1993; 21: Shapiro, SM, Young, E, De Guzman, S, et al. Transesophageal echocardiography in diagnosis of infective endocarditis. Chest 1994; 105: Birmingham, GD, Rahko, PS, Ballantyne, FD. Improved detection of infective endocarditis with transesophageal echocardiography. Am Heart J 1992; 123: Zabalgoitia, M, Garcia, M. Pitfalls in the echo-Doppler diagnosis of prosthetic valve disorders. Echocardiography 1993; 10: Daniel, WG, Mugge, A, Grote, J, et al. Comparison of transthoracic and transesophageal echocardiography for detection of abnormalities of prosthetic and bioprosthetic valves in the mitral and aortic positions. Am J Cardiol 1993; 71: Alton, ME, Pasierski, TJ, Orsinelli, DA, et al. Comparison of transthoracic and transesophageal echocardiography in evaluation of 47 Starr-Edwards prosthetic valves. J Am Coll Cardiol 1992; 20: Roe, MT, Abramson, MA, Li, J, et al. Clinical information determines the impact of transesophageal echocardiography on the diagnosis of infective endocarditis by the Duke criteria. Am Heart J 2000; 139:945.